When she noticed a lump on her breast, Ellen started trying to save money for a mammogram.
What she should have done was call a doctorimmediately, health officials say, but she can't afford a telephone,much less a large doctor bill or monthly insurance premium. Her husband's modest income is too high to allow them to qualify for Medicaid.
A nurse with the Carroll County Health Department happened to hear about Ellen through a friend, and arranged for her to visit a doctor immediately.
"We ended up taking money out of our emergency fundfor that," said Donna Hopkins, director of nursing for the department.
Ellen's lump turned out not to be cancer, but it illustrates a problem for which the county still has no cure -- access to medical care regardless of income.
Dr. Janet Neslen, Carroll's health officer, estimates that 4,400 county residents like Ellen are in the "grayarea" of making too much money to qualify for Medicaid, but not enough to afford insurance or medical bills.
Another is Elizabeth Eckert, 77, of Hampstead, who said she makes just a few dollars over the Medicaid limit. She has been putting off cataract surgery because she can't afford the $700 cost on a Social Security income.
"If I have a cold, I doctor myself," she said, adding she's lucky to be in good health.
"Do we believe health care is a right, or do we believeit should go to people who can afford to pay for it?" Neslen said. "The United States still hasn't made up its mind. I've always believed health care is a right."
Neslen chairs a Carroll County League of Women Voters committee studying the issue.
At the same time, sheand other members of the Carroll County Medical Society are looking at how doctors in the county can organize free or low-cost care.
One program they will study is Allegany Health Right Inc., based in Cumberland, Md. Formed in 1988 by a consortium of social service and health professionals, the private, non-profit system matches low-incomepatients with area doctors, a pharmacy and two hospitals that donateservices and drugs.
Neslen said the medical society started looking into Health Right after complaints that Medicaid patients were having trouble finding doctors who would participate in the program.
But the bigger problem has been the gray area of people who can't geta Medicaid card, but can't afford a doctor, she said.
And with nothing concrete to offer them, she's reluctant to call for them to step forward and be counted.
"It's unethical to screen people or ask them to come forward when you have nothing to offer them," Neslen said. "That's an old, old law in public health."
Documents show the county has 3,200 people receiving Medicaid. Under state guidelines, a family of four would have to earn less than $6,000 a year for all members to qualify for Medicaid. The figure is based on 45 percent of the federal poverty level of $13,300 for a family of four. Children through age 7 and pregnant women may qualify at up to 185 percent of poverty level.
Those just above those limits rely on limited emergency funds at the Health Department and the Salvation Army. And many physicians always have given some free care to patients they know can't afford to pay, Neslen said.
She said the medical society is looking at ways to share the duty among the 92 internists, pediatricians and family doctors here.
Allegany Health Right divides patients among 107 doctors -- about 90 percent of all general practitioners and specialists in the county, said Walter Bosley, the program's executive director. Dentists will join soon, he said.
From a population of 75,000 in Allegany, the organization has about 500 people getting freecare at any given time. Bosley estimates that several thousand more need the help and would qualify. A family of three could qualify by earning up to $13,200 a year.
"There's still a lot of really proud people who won't come to us," he said.
Allegany Health Right's budget is $40,000 a year from donations from religious, corporate, county and state sources. Expenses are salary for Bosley and two part-timeworkers. Several volunteers donate time.
St. Mary's, Garrett, Washington and Baltimore counties also are studying Allegany's model, which itself is a modified version of one in West Virginia.
Bosley stresses the program is not the cure-all for the nationwide problems in access to health care.
"Allegany Health Right is not the answer to the uninsured problem. We're a stopgap to help people right now. We hope for a solution to come around and put (us) out of business," he said.